Exam 1 Flashcards
(167 cards)
1
Q
Leading Causes of Death
A
Medical errors and “health care-associated infections”
2
Q
Medical errors and health care-associated infections each kill more Americans than….
A
AIDS, breast cancer or vehicle accidents per year
3
Q
Probability of dying from a health care associated infection or medical error
A
1 in 760 hospital admissions
4
Q
The most common way infections are spread
A
Touching a patient or equipment, then touching another patient without washing your hands.
5
Q
How infections are spread
A
- Infectious Agent (germs)
- Source of Infection (human/animal/object)
- Portal of Exit (cough/blood/diarrhea)
- Mode of Transmissions (ex. your hands)
- Portal of Entry (skin/lungs/GI/GU)
- Susceptible Host- Our Patients
6
Q
Compliance with handwashing by healthcare staff
A
only 30% to 50%
7
Q
When to was hands
A
Entering and leaving patient rooms.
8
Q
The most important way we can reduce infections
A
Frequent handwashing
9
Q
Always use soap and water if
A
Hands are visibly soiled, presence of infections, before and after eating, after using the restroom, wash hands with friction for at least 20 sec, and after removing gloves and between glove changes.
10
Q
Bed Safety
A
Bed in low position, bed wheels locked, lift side rails up x2, and call light in reach
11
Q
Principle-Based Procedures
A
- Wash hands before and after care
- Gather supplies
- Introduce self and others
- Identify patient with 2 identifiers
- Explain procedure
- Provide privacy
- Use good body mechanics
- Provide patient safety
12
Q
Temperature
A
measurable heat in the body
13
Q
Pulse
A
detectable rhythm of the heart contractions
14
Q
Respirations
A
frequency of breaths
15
Q
Blood pressure
A
pressure of blood in the arteries
16
Q
Pulse Oximetry
A
amount of oxygen in the tissues
17
Q
Vital signs
A
a means of assessing vital or critical physiological functions
One of the most frequent assessments you will make as a nurse
18
Q
Why are vial signs checked
A
Monitor body systems, detect changes in health statues, evaluate effectiveness of interventions, identify life-threatening warning signs
19
Q
When are vital signs checked
A
performed no a regular basis
Frequency determined by physician order and/or nursing judgement, client’s condition, facility standards, and location of patient.
20
Q
Standards for Monitoring Stable patient
A
every 4-8 hours
21
Q
Standards for Monitoring Postsurgical patient
A
every 15-60 minutes
22
Q
Standards for Monitoring critical/unstable patient
A
every 5 minutes
23
Q
Standards for Monitoring home health settings
A
each visit
24
Q
Standards for Monitoring clinics
A
each visit
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Standards for Monitoring skilled nursing facilities
weekly to monthly
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Interpreting Vital Signs
Compare the patient's values to normal values then compare with previous values
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Temp: under tongue
Oral; most common site
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Temp:Ear
Tympanic; adults and children
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Temp: Forehead
Temporal; infants/small children
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Temp: Armpit
Axillary; healthy newborns
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Temp; rectal
Do not use for newborns, patients with low white counts, spinal cord injuries, diarrhea, rectal surgeries, quadriplegics.
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Temperature Conversion Fahrenheit to Celsius
F temp minus 32, Multiply by 5, divide by 9
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Temperature Conversion Celsius to Fahrenheit
C temp x 9, divide by 5, add 32
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Pulse Locations: Apical Pulse
Most accurate site; apex of heart at point of maximal impulse, left midclavicular line, 5th intercostal space, use stethoscope to listen (auscultate), count for 1 minute.
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Pulse Locations: Radial Pulse
Most common peripheral site, under thumb on wrist.
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Temporal
side of head at temple
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Carotid
side of neck below jaw
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Brachial
Inner side of elbow
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Radial
Thumb-side of inner wrist
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Femoral
Bend of leg at groin
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Popliteal
Behind knee, inner side
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Posterior tibial
Below inner ankle
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Dorslis pedis
Top of Foot
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Temperature normal range
95.9-99.5 F (35.5-37.5C)
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Pulse normal range
60-100 beats per minute
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Respirations normal range
12-20 breaths per minute
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Pulse Oximetry normal range
>95% Saturation of peripheral oxygen
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Blood pressure normal ranges
Systolic 90-120 mm Hg
| Diastolic 60-80mm Hg
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mm Hg
millimeters of mercury
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Physiology of Blood pressure
Heart beat forces blood against arterial walls, creates a pressure wave as left ventricle contracts and then relaxes, peak phase (highest) Systolic pressure, resting phase (lowest) diastolic pressure.
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Stethoscope
Used to auscultate the systolic and diastolic pressure, heard as Korotkoff (thumping) sounds
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Sphygmomanometer
Vinyl or cloth cuff, a pressure bulb with regulating valve, and manometer
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Hypotension Systolic
Systolic blood pressure <100 mm Hg, some patients normally have low BP, and ask if patient is light-headed or dizzy
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Hypotension Orthostatic or postural
A sudden drop in BP, a change position from lying to sitting or standing
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Hypertension stats
BP persistently higher than normal, diagnosed when systolic is >140 mmHg or diastolic is >90 mmHg, tested on two or more separate occasions
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Hypertension
Primary or Essential Hypertension, diagnosed when there is no known cause for the increase, accounts for about 90% of all hypertension
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Hypertension facts
A major cause of illness and death in US, increases stress on heart and blood vessels, severity is directly related to the degree of elevation, ntreated may lead to heart attack, heart failure, peripheral vascular disease, kidney damage, or stroke
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BP points to remember
Measurements on the dial are in 2 mm HG increments, always ask the patient for the arm they prefer BP to be taken. Do not use the side with surgery, IV, or stroke
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Responsibility and delegation for vital signs
Nurses can delegate the activity of taking vital signs
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Nurses are responsible for vital signs
Interpretation of vital signs, vital sign trends, decisions based on abnormal findings
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Purpose of the Nursing Process
To help the nurse provide goal-directed, patient-centered care; a thinking template to make clinical judgement; the art of nursing - based on knowledge, experience and intuition
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Why do we use the nursing process?
Required by the American Nurse's Association in the Nursing scope and standards of practice, Required by State Boards of Nursing in US, and Required for facility Accreditation
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ADPIE
Assessment, Diagnosis, Planning, Implementation, and Evaluation
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Assessment
Collect facts and data
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Objective data
Lab test, V/S, someone else comes in and they will get very similar results
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Subjective data
Patient, family , caregiver, etc. Ex: the patient says they are nauseous
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Diagnosis
Actual= patient response to an actual problem, risk = for a potential problem (teaching patient about getting screenings), improve health = health promotion and wellness (testing vision and hearing)
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Planning
Prioritize patient diagnoses, goals - reverse or eliminate problems found in nursing diagnoses, set short and long-term goals that are measurable, plan interventions
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Implementaion
Put the plan into action. This is what you do in patient care
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Evaluation
Evaluate the effectiveness of the care provided, evaluate the patient's response, evaluate whether goals were met, evaluate whether the plan needs to be revised.
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Nursing Process is Cyclical
Use critical thinking skills, reassess the patient, identify new diagnoses, revise the plan and modify goals, implement new actions, re-evaluate outcomes
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Verbal communication
words only 7%
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Nonverbal communication
Body language 55% and voice inflection 38%
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Types of verbal commmunication
Spoken words (privacy), written words (legal), and electronic words (confidential)
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Why is communication essential for nurses
assessing patients, educating patients, advocating for patients, providing patient safety, and collaborating with patient and health team.
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Types of nonverbal communication; body language
Posture, stance, gait, facial expressions, eye contact, touch and hand gestures
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Phases of the Nurse/Patient Relationship
Stage 1: Pre interaction phase, Stage 2: Orientation phase, Stage 3: Working phase, stage 4; Termination phase
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Preinteraction phase
Gather information prior to meeting patient
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Orientation phase
Meet the patient- introduce self, sit down, ask, observe, assess, interview, identify patient's needs
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Working phase
Use therapeutic communication, develop and implement care plan, collaborate with others on the team
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Termination phase
Evaluate outcomes, and tronsition patient to next step
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What is therapeutic communication
Patient-centered (it's about the patient), goal-directed it's about the Patient's goals), it's ALL about the Patient.
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Empathetic
Put yourself in another's place
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Respectful
Use proper name, provide privacy
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Genuine
Honest and truthful
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Collaborative
be flexible, partner with the patient
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Advocacy
speak up for patient's rights
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Techniques of Therapeutic communication (10)
Call the patient by their proper name, use open-ended questions (what or how), Actively listen (sit down, make eye contact), and share observations (you look sad, afraid, concerned), convey acceptance (everyone has a story), offer assistance (how can I help you?), use humor appropriately (puppies and kittens), paraphrase patient comments, seek clarification (be on the same page), provide information in living room language, and summarize the conversations (the BIG points)
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What is non-therapeutic communication
Social conversations, self-absorbed, can be hurtful, and damages professional relationships
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Nontherapeutic communication
Asking "why didn't you", using closed-ended questions, changing the subject, gibing false assurances (everything is going to be just fine), giving advice, and giving stereotyped responses (don't worry we've done this a million times), showing disapproval or disagreement, failing to listen, excessive self-disclosure, comparing patient experiences, being defensive, using personal terms of endearment
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Legal, Ethical and Safety issues
Legal- Confidentiality and Social Media, Ethical- professional boundaries (sharing personal info, inappropriate touch), Patient Safety- $200 billion in added costs (70-80% of medical errors are due to poor communication
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Sentinel events
death of serious injury
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Collaborative communication
Important information for the team, coordination of care, communication hand-off (SBAR)
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SBAR
Situation, background, assessment, and recommendation
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Vision Impaired
make sure patient has glasses on, provide good lighting in room, use clock face numbers for location of items, provide large-print, and/or audio material, and use a light touch to arm or shoulder to alert patient of you presence.
96
Hearing impaired
Assist with hearing aids/check batteries, always face patient when speaking, decrease background noise, speak clearly 3-6 ft from patient, use white board for written communication, always check for understanding, use sign language interpreter as needed
97
Physical Impairments
Dyspenea, pain
Use nonverbal cues (hand squeeze/head nod), watch for facial expressions, white boards/erasable markers for nonverbal patients
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Cognitive impairments
Dementia, brain injury
| Consult with family for helpful ideas, avoid confrontation, and accept their reality
99
Language/Culture/Literacy
Use facility interpreter service (do not use family members for important information), ask patient about cultural practices to provide best care (ask about personal space), speak to all patients using living room language and shame-free environment, only teach 2-3 key points at a time, and use tech-back/show-me for understanding
100
Family/caregiver communication
Get patient's permission, educate family/caregivers about care issues, listen and observe family dynamics, provide written and/or audio materials, allow time for hands-on demonstrations, check for other supportive networks
101
Employers top 5 skills/qualities
Communication skills, strong work ethic, teamwork skills, analytical skills, initiative
102
General concepts of hygiene essential to patient care
cleans skin to decrease infection, provides comfort, promotes health, and improves self-image
103
Activities of Daily Living
Bathing, Dressing, Grooming, Eating, Oral Care, and Toileting
104
Physical factors that influence hygiene and self-care
Pain-Limits mobility and energy
Mobility deficits: decreased range of motion, weakness, balance
Sensory deficits: Safety concerns and decreased independence (sight and numb touch)
Fatigue: loss of strength due to physiologic changes in the body
105
Cognitive impairments
Cannot problem-solve ADL processes, and forgets when hygiene was performed
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Emotional Disturbances on Hygiene
Profound lack of energy for ADLs, and altered reality does not include hygiene
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Factors that influence hygiene and self-care
Personal preference (time of day and how often), culture and religion, Economic status, and knowledge level.
108
Bathing Guidelines
Wash from distal to proximal to improve venous return
Wash from clean to dirty areas
Control temp of water; allow patient to check water temp
Change water often
Wash, rinse and dry before moving to next area
109
Bathing a patient
Face and neck (water only), hands and arms, chest, abdomen, feet and legs, perineal area, back, and rectal area
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Common types of bath
Assisted shower (bathe hard to reach area), Partial bath (bathe necessary areas; face, hands, underarms, perineum) Bed bath (complete, partial, and assisted)
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Recommendations Physical Intimate Touch
Project a professional appearance
Speak clearly
ask if patient can complete own care
ask if patient would like a second assistant to be present
Ask if nurse gender preferred
Ensure Privacy
Get permission first before making contact
Use touch that is firm, not rough; unhurried not lingering
Look for verbal/nonverbal cues of discomfort, stop, ask for feedback
112
Oral Care
Provide oral care every 2 Hours if NPO (nothing by mouth), removes bacterial, reduces risk of tooth decay, reduces risk of respiratory and cardiac infections, and improves appetite
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Oral care for unconscious patient
Provide oral care every 2 hours, position patient on side, head lower than body, use minimal water, have suction available
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Care for dentures
Place wash cloth in bottom of sink before brushing, and store in labeled denture cup in water
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Care of Eyes
Clean inner to outer, no soap
Special care for contact lenses
Special care for artificial eyes
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Care of Ears
Special care for hearing aids
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Care of feet
Special care with diabetes and peripheral nephropathy
Check facility policy about trimming nails
wash and dry feet completely
No lotion between toes or bottom of feet
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Label and properly store all personal items including
Dentures, eye glasses, contact lens, hearing aids, and jewelry
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Safety actions before leaving patient's room
Leave patient in a comfortable safe position
Return bed to low position, lock wheels, raise side rails x 2, and call light in reach
Wash hands before leaving the room
120
Hygeine Procedures
Complete Bed bath, perineal care, making an occupied bed, brushing and flossing teeth, denture care, oral care for unconscious patient, shaving a patient, and caring for hearing aid.
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Principles of Body Mechanics
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Keep spine in natural alignment
Elevate work surface to center of body
bend from knees, not waist, when lifting
Feet apart for wide base, avoid twisting
Keep patients or objects close to body
Use lifting devices when appropriate
Request help when needed
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122
Activity Intolerance
Decreased capacity for exercise and ADLs
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Risk factors for activity intolerance
Heart failure, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, and Prolonged Bedrest (shortness of breath, dyspnea, profound fatigue)
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Immobility
Physical Impairment
Osteoporosis, limited joint mobility, cerebrovascular accident, spinal cord injury, brain injury, and balance/equilibrium problems.
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Effect of Activity intolerance and immobility on body systems: Cardiovascular System
Increased heart rate, venous stasis, orthostatic hypotension, Deep Vein Thrombosis (DVT)
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Effect of Activity intolerance and immobility on body systems: Pulmonary System
Pulmonary edema, pneumonia, and atelectasis
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Effect of Activity intolerance and immobility on body systems: Integumentary system
Tissue ischemia, and pressure ulcers
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Effect of Activity intolerance and immobility on body systems: Musculoskeletal System
Muscle atrophy, joint contractures (everything curls up), foot drop, and bone loss/osteoporosis
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Effect of Activity intolerance and immobility on body systems: Gastrointestinal system
Decreased peristalsis, constipation, bowel obstruction/paralytic ileus
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Effect of Activity intolerance and immobility on body systems: Genitourinary System
Urinary stasis, Urinary tract infections, renal calculi (kidney stones)
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Effect of Activity intolerance and immobility on body systems: Nervous System
Altered proprioception, and altered balace
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Effect of Activity intolerance and immobility on body systems: Psychosocial Impact
depression/hopelessness, loneliness/isolation, altered sleep patters, and disorientation
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Lung expansion
raise head of bed, turn/cough/deep breath every 2 hours, use incentive spirometer every one hour while awake
134
Prevent blood clots
Active and passive ROM, sequential compression devices, anti-embolism stockings, keep hydrated, encourage self-care of ADLs
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Prevent orthostatic hypotension
Raise head of bed, dangle at side of bed, check v/s
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Prevent atrophy
Active and passive ROM, overhead trapeze bar, and footboard
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Prevent skin breakdown
Turn/reposition every 2 hours or more often if needed, proper alignment in bed, use pillows/wedges/trochanter rolls, and keep skin clean and dry
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Prevent shear
by using draw sheet to prevent drag when repositioning
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Supine
Laying on back
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High Fowler's
90 degrees
141
Semi-Fowler's
45 Degrees
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Sim's
Side-lying with hip and knee flexion
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Prone
lying on abdomen
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Prevent altered digestion
healthy diet, increase protein and fiber intake, adequate fluids, promote regular toileting
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Prevent infection and risk of renal calculi
encourage adequate fluid intake and emptying bladder
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Prevent depression/loneliness
Encourage visits from family/friends, include patient and planning care, offer spiritual/chaplain care as needed, prevent sleep disruption, engage in conversation, and orient to reality
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Fall risk factors
Over age 65, history of falls and fear of falling, balance or gait problems, muscle weakness, visual impairment, neurological impairment, cognitive impairment, bowel or bladder incontinence, cardiovascular issues, and multiple medications
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Fall Precautions
Assess every patient for risk of falls
Frequently observe patients (every 2 hours during day and every 1 hour at night)
Bed safety
Answer call light quickly
Good lighting in room, nightlight at night
Keep patient's belongings within easy reach
Use gait belt and nonskid socks/shoes
Keep walkways clear, clean and dry
Use proper fitting clothing
Familiarize patient with environment
Patient return-demo call light
Patient to use handrails in bathroom and hallways
Keep wheelchair wheels locked when stationary
Communicate and document fall risk to health care team (armband, sign on door)
149
Interventions for Safe Mobility
Gait belt, walker, wheelchair, crutches, cane
Dangle patient first, raise head of bed, turn patient and lower legs to floor, sit patient on side of bed for several minutes, and have patient move legs before standing
Use transfer board and mechanical lift as necessary
150
Active ROM
Patient can do it themselves
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Passive ROM
We have to move the joint for them.
152
Flexion
Bending at a joint in the natural direction of movement
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Extension
moving from the flexed position to a neutral or straight position
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Hyperextension
moving beyond a straight or neutral position
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Rotation
Pivoting a body part on its axis
156
Abduction
movement of a limb in a direction away from the midline of the body
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Adduction
Movement of a limb in a direction toward the midline of the body
158
Circumduction
A combination of movements that causes a body part to move in a circle
159
External rotation
rotation from a joint in the direction away from the midline of the body
160
Internal Rotation
Rotation from a joint in the direction toward from the midline of the body
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Supination
Rotation of the palm of the hand upward or in the anterior direction
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Pronation
Rotation of the palm of the hand downward or in the posterior direction
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Opposition
The relationship of the thumb and fingers for the purpose of grasping objects
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Eversion
movement of the ankle to turn the sole of the foot laterally(away from the midline)
165
Inversion
movement of the ankle to turn the sole of the food medially (toward the midline)
166
Dorsal flexion
Flexion of the ankle in the direction of the dorsal surface
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Plantar Flexion
Flexion of the ankle in the direction of the plantar surface
